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Table 2 Elements of Chronic Care Model (CCM) included in each program

From: The prevention and management of chronic disease in primary care: recommendations from a knowledge translation meeting

CCM component P1 P2 P3 P4 P5 P6 P7
Health system
Visibly support improvement at all levels of the organization, beginning with the senior leader      
Promote effective improvement strategies aimed at comprehensive system change      
Encourage open and systematic handling of errors and quality problems to improve care    
Provide incentives based on quality of care        
Develop agreements that facilitate care coordination within and across organizations  
Delivery system design
Define roles and distribute tasks among team members
Use planned interactions to support evidence-based care
Provide clinical case management services for complex patients     
Ensure regular follow-up by the care team
Give care that patients understand and that fits with their cultural background    
Decision support
Embed evidence-based guidelines into daily clinical practice
Share evidence-based guidelines and information with patients to encourage their participation
Use proven provider education methods  
Integrate specialist expertise and primary care   
Clinical information systems
Provide timely reminders for providers and patients    
Identify relevant subpopulations for proactive care   
Facilitate individual patient care planning
Share information with patients and providers to coordinate care
Monitor performance of practice team and care system   
Self-management support        
Emphasize the patient’s central role in managing their health
Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up
Organize internal and community resources to provide ongoing self-management support to patients  
The community
Encourage patients to participate in effective community programs
Form partnerships with community organizations to support and develop interventions that fill gaps in needed services   
Advocate for policies to improve patient care